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Dose
Elemental iron
Pregaday
Ferrous sulphate (dried)
Ferrous Gluconate
Ferrous fumarate
200mg
195mg
210mg
195mg
2
3 + folic acid 400mcg
6 + folic acid 400mcg
3 + folic acid 400mcg
Non-anaemic iron deficient women can be offered 65mg elemental iron with a repeat
Hb and serum ferritin test after 8 weeks. Those at risk include previous anaemia
sufferers, multiple pregnancy, less than 1 year interdelivery interval, vegetarians and
pregnant teenagers, Consideration to those who pose a high risk of PPH or
Jehovahs witnesses should also be given.
Anaemic women may require additional precautions for delivery, including delivery in
hospital, available iv access, blood G&S, active management of the third stage of
labour and plans for excess bleeding. If the patient has a Hb<105g/L they should be
advised to deliver in hospital.
Folic acid requirements are increased in pregnancy because of the rapidly dividing
cells in the fetus and elevated urinary losses. As the neural tube closes by day 28 of
pregnancy, a supplementation of folic acid will not prevent neural tube defects.
However, it will contribute to other aspects of maternal and fetal health.
Refractory anaemia, which has been unresponsive to the appropriate trial (i.e. two to
three weeks of oral iron), should be re-evaluated with serum Ferritin, B12, folate
levels and repeat full blood count levels to show failure in oral therapy. (Ferritin
reflects iron stores and a level less than 30g/l indicates iron depletion.)This would
initially erase the issues of patient compliance who should be encouraged to take this
medication. Following this you should treat the patient with intra-venous iron therapy.
The decision for intravenous iron therapy should only be made by a senior member
of obstetric staff.
Referral to DAW/ANC should occur if there are significant symptoms and/or severe
anaemia (Hb<70g/L) or late gestations (>34 weeks) or if there is failure to respond to
oral iron with an increase in Hb over 2-3 weeks. Other causes that could be
contributing to the anaemia should be excluded, such as folate deficiency or anaemia
of chronic disease.
Table 1
Indications for assessment of serum ferritin
Anaemic women where estimation of iron stores is necessary
Known haemoglobinopathy
Prior to parenteral iron replacement
Non-anaemic women with high risk of iron depletion
Previous anaemia
Parity 3
Consecutive pregnancy <1 year following delivery
Vegetarians
Teenage pregnancies
Recent history of significant bleeding
Non-anaemic women where estimation of iron stores is necessary
High risk of bleeding
Jehovahs witnesses
Weight 70kg
<100
1500mg
2000mg
100
1000mg
1500mg
A single dose should not exceed 1000mg of iron (20ml) per week
Undiluted solution up to 1000mg iron (up to a maximum of 15mg/kg)
A small venflon (blue/pink) is adequate, a butterfly is suitable for a small bolus.
Table 3
Dilution plan for ferinject for iv drip infusion
Ferinject
Iron
Maximum amount
of sterile 0.9%
sodium chloride
2-4ml
100-200mg
50ml
4-10ml
200-500mg
100ml
10-20ml
500-1000mg
250ml
Minimum
administration time
6 min
15 min
Oral iron must not be administered concomitantly with a course of IV iron or until
5 days after the last dose.
Height cm
155
157
160
163
165
168
170
173
175
3.3 Contraindications
Anaemia not attributable to iron deficiency
Iron overload
A history of hypersensitivity to parental iron preparations
History of cirrhosis of the liver
Acute or chronic infection
Active rheumatoid arthritis
First trimester of pregnancy
Acute renal failure
Patients with a history of asthma, eczema or other atopic allergy
Drug hypersensitivity including mono- or di-, saccharide complexes and
dextran
3.4. Response
Due to iron metabolic pathways, a rise in reticulocyte count will occur during the
second week and thereafter one can expect a rise in haemoglobin of approximately
1.5g/week after 2 weeks.
3.5. Dosage - Total dose infusion
NB. If prescribed by SHO grade the prescription dose must be checked by obs
reg / con before admin.
The dose calculation for CosmoFer is based on patients body weight according to
the table below and is diluted in 500mL of normal saline.
1 mL Cosmofer ~ 50 mg Iron
How to select the correct dose of CosmoFer
In the left hand column, find the body weight closest to the patients body weight,
read across this row to the column headed by the patients current haemoglobin
value, values for body weight and haemoglobin must be rounded up or down to the
nearest stated value. The number at this point is the dose required (in milligrams of
iron).
Body
Weight
(kg)
40
45
50
55
60
65
70
75
80
85
90
7
1075
1125
1200
1275
1350
1425
1500
1575
1650
1700
1775
8
975
1025
1100
1150
1200
1275
1325
1400
1450
1500
1575
9
875
925
975
1025
1075
1100
1150
1200
1250
1300
1350
10
775
800
850
875
925
950
1000
1025
1075
1100
1125
11
675
700
725
750
775
800
825
850
875
900
925
12
575
600
600
625
625
650
650
675
675
700
700
Example:
Body weight 74kg,
Current Hb 8.2g/dL
Rounding up / down weight 75kg
Hb 8g/dL
Dose is 1400mg iron (28 ml Cosmofer injection) in 500 ml Sodium Chloride 0.9%.
CosmoFer must be added to 500 mL of Sodium Chloride 0.9% IV infusion and
infused over 4 hours. The patient should be observed for 1 hour after completion of
the infusion.
For subsequent doses the 25mg test dose must still be given, however there is no
requirement for the one hour observation period.
Example:
25mg X 500mL
1400mg
= 9mL
1st trimester
Hb<110g/L
2nd-3rd Trimester
Hb<105g/L
Postpartum
Hb<100g/L
Iron
deficiency
alone
65mg
elemental
iron OD
e.g. FeSO4
200mg OD
Improvement in Hb
Advise continuation
until 3 months after
Hb within normal
range
4. Record keeping
It is expected that every episode of care be recorded clearly, in chronological order
and as contemporaneously as possible by all healthcare professionals as per
Hospital Trust Policy. This is in keeping with standards set by professional colleges,
i.e. NMC and RCOG.
All entries must have the date and time together with signature and printed name.
Cross references
TRW/MMA/POL/271/5 Intravenous Drug Administration Policy
TRW/MMA/POL/265/2 Policy for the Safe and Secure Handling of Medicines
Antenatal Guideline 44 Guideline Development within Maternity Services
Antenatal guideline 31: Maternity Hand Held Notes, Hospital Records and Record keeping
References
National Collaborating Centre for Womens and Childrens Health Commissioned by the national
Institute of Clinical Excellence (2003) Screening for haematological conditions Chapter 8 pp.
67 71 in Antenatal care: routine care for the healthy pregnant woman. RCOG Press: London.
British National Formulary Sect 9.1.1.1
UK guidelines on the management of iron deficiency in pregnancy, British Journal of
Haemoatology, 2012, 156, 588-600
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